Big Food, the Diet Industrial Complex and now, miracle drugs?

Three-quarters of all Americans are overweight or obese. Despite the diet industry’s ballooning revenue at some $80 billion, whatever they are doing clearly is not working – which is a great business model but a pretty bad outcome for customers. With a whole new category of diabetes drugs being prescribed off-label for weight loss, what can we expect next?

 Struggling with your weight? It’s because you are outmatched

As the Washington Post’s Tamar Haspel observes, “When three-quarters of humans can’t navigate the system successfully, the problem is the system, not the humans.” She notes that the food industry “developed product after product that was deliberately designed to be overeaten.” She uses the analogy of trying to play tennis with Serena Williams – no matter how much you practice, you’re unlikely to triumph.  

That’s because the companies that you can think of as “big food” have gotten really good at helping us to consume more of it. The so-called “green revolution” of the 50’s and 60’s allowed for the application of industrial methods to farming. Earl Butz, the Nixon-era Secretary of the United States Department of Agriculture, under a mandate from the President to combat rising food prices to a restive middle class told farmers to “get big or get out.” Farms consolidated. Farmers bought industrial-scale equipment, more pesticides, and artificial fertilizers to take advantage of every inch of land, spurred in part because the fossil fuels behind many of these innovations were relatively inexpensive. As fruit and vegetable farmers increased their production, that made feeding animals cheaper. Commodity crops like corn, wheat and soy facilitated the establishment of CAFO’s (concentrated animal feeding operations), which could produce meat at formerly unimaginable scale.

The thing about capitalism is that when pricing doesn’t feature in the total cost of a practice, it is all too easy for actors to privatize gains and socialize costs (a point often made by Rebecca Henderson). The benefits of all that industrial farming went to markets favoring quantity over quality, with little reflection of the costs in terms of soil, water, and public health. Moreover, mass production, by some accounts, was a boon, helping address big issues such as world hunger.

The consequence, according to a critique by Rand Gifford of Mother Earth Food, is that “the industrial food system has created a market that favors traits such as uniformity, size, and growth rate over flavor and nutritional density. This is true in both plant and animal production and in the end you get a product that may look good, but is actually full of toxins and virtually flavorless (for more on this read ‘The High Cost of (not) Eating Fresh’). Since we tend to slather our food in dressing, sauce, butter, and salt, the actual flavor of the food itself is oftentimes deemed irrelevant with a tendency to focus on price per pound over nutrients per serving.”

By some accounts, food companies spend upward of $14 billion per year on marketing, with more than 80% of it spent to promote processed food with artificial ingredients and lots of sweeteners. Further, because of the way food is distributed, the healthiest food choice in a given situation is often not available, affordable or easy. The burden of dealing with food marketing practices falls hardest on low-income people, who also need to spend a disproportionate amount of their income on food. The healthier choice of unaltered fruit? Virtually zero advertising buzz.  

Restaurants, as well, share some of the blame. Portion sizes have ballooned. A typical fast-food burger 

today is 3 times larger than it was in the 1950’s. Sweetened sodas have become super-sized. And while we’d prefer to think otherwise, the more food on your plate, the more likely you are to eat. And you don’t subsequently consume fewer calories, either to make up for the excess. Result? Weight gain.  

An unexpected beneficiary - The weight-loss industry

In an ironic complementarity, the weight challenges largely created by Big Food spawned an entire $80 billion industry dedicated to correcting the problems of overconsumption. The flagship company built on the premise of helping people combat the pervasive outcome of too much readily available food was Weight Watchers, founded in 1963. In addition to regular old willpower, Weight Watchers’ founder Jean Neditch “turned the drab, frustrating diet into a quasi-religious quest, with membership commitments, eating systems, inspirational meetings and cookbooks, food products and motivational success stories to reinforce the frail will.”

Companies emphasizing support for willpower such as Atkins, Noom, Nutrisystem and more sprang up. Some featured specially-prepared food kits, some exercise programs, some point-counting and others community gatherings with a near-religious fervor. I’ll never forget attending a Weight Watchers meeting shortly after our second child was born. It was all a bit cult-like, with the weigh-ins and record keeping. The last straw for me, though, was people talking obsessively about their strategies for Halloween candy (“I make my husband donate it”) and even how much gravy they might enjoy (a quarter cup) during Thanksgiving!  

For all this, however, diets seldom work once a person has become obese. As Alix Turoff, a registered dietician and personal trainer observes, “Most of my clients have been on a ton of different diets. They’ve been on everything. No one can follow them because they’re so insanely restrictive.” 

Big Pharma Enters the Picture

So we have the unintended consequence of Big Food’s business model making many, if not most, people fatter and sicker, and the ineffective antidote offered by the diet industry. Enter a new kind of competition, offering drugs that promise weight loss without willpower.  

These were initially developed to treat diabetes (which I wrote about here a while ago), and are termed GLP-1 agonists.  They work by triggering insulin release, blocking sugar production in the liver, and making users feel full. In clinical trials, adults taking Wegovy saw an average weight loss of nearly 15% of their initial body weight. And adolescents saw an average weight loss of about 16% of their initial body weight. Ozempic is another semaglutide drug whose mechanism works the same way.

The drugs promise to provide some armor against the lure of food marketing by slowing down the absorption of food, making users feel fuller for longer, as well as decreasing appetite. It seems more than ironic that one major industry (pharmaceuticals) is addressing the unintended negative consequences for public health created by another (big food). One very interesting consequence of taking the medications is that people who were driven by addictive behaviors – which some call “food noise” find that the chatter disappears and they can establish a more arms-length relationship with food. Some patients also find that being on the drugs eliminates their desire for alcohol as well.  

For the diet-and-exercise weight loss firms, this is an existential threat. Do they stick to their guns and continue to promote diet and exercise? Or do they get on board with the new situation and adopt these therapies themselves?  

Decisions seem to favor embracing the prescription model. In March of 2023, Weight Watchers announced it was buying a telehealth company, Sequence, that offers users access to Ozempic, Wegovy and Trulicity, for $106 million. Noom, struggling with a stalled IPO, and complaints that it creates symptoms close to an eating disorder, announced a service called Noom Med in May of 2023.  

None of this is cheap for end users. Use of these platforms can cost from $99 to $140 per month, and that is without covering the cost of the drugs themselves, which can run up to $1,000 or more per month, if not covered by insurance. And of course, insurance carriers are not thrilled at the prospect of having to pay for expensive medication that up to 130 million Americans alone might qualify for, and which don’t offer a cure, but which demand continual usage. Which raises critical issues having to do with health equity and availability of the drugs for people who need them to treat conditions such as diabetes, as opposed to people using them for cosmetic purposes.  

The drugs are intended for people suffering from diabetes, and offered a promising alternative to the usurious ways in which insulin has come to be marketed (as I’ve written about before). Unfortunately, the government has now declared a nationwide shortage of the drugs because of the intense interest in using them to support people’s weight loss goals, whether they are dangerously obese or not.  

As with so many other situations involving healthcare, people who can afford expensive treatments are getting them, while the people living on slimmer margins can’t. And unfortunately, people on the lower end of the income scale are most likely to be vulnerable to being obese and lacking access to adequate nutritional choices.  

For payers, an interesting question is whether covering the new drugs now will save them the expense of treating obesity-related diseases down the road. But until we have data that supports this idea, it’s highly likely that they will continue to treat weight loss as a cosmetic consideration, not a chronic disease.  

The cost of all this versus simply providing better information about what we are eating

A fascinating public policy question is whether we as a society can absorb the cost of food production as it currently exists AND $80 billion in spending for diet companies AND the expense of large numbers of people using costly drugs for a lifetime?

For the food producers and the traditional weight loss firms, one wonders whether the market will eventually shrink, along the lines of what happened to Big Tobacco as people realized the devastating health effects of smoking. If shrinking the cigarette business is “one of our nation’s greatest public health success stories,” perhaps figuring out a path for more people to have a healthy relationship with food and their weight could head in a similar direction.

As with smoking, perhaps if people got safe, reliable information about what is in the food they eat and how to more simply make better food choices, they would do so. I’m very taken with the approach taken by “Eating For Your Health,” a not-for-profit whose Executive Director is Marion Reinson. As she put it in a recent interview, “We provide the information, and it is our belief that when people are given information, they’re going to want to do the best thing that they can for themselves. They’re going to want to advocate for themselves…. We want people to feel that they’re empowered to make a difference in their own health, and food is that frontline.”  

She says that the knowledge in understanding that a can of Coke, which contains 39 grams or nearly 10 teaspoons of sugar, is convincing enough on its own. “That’s a lot of sugar, and your body just eventually is unable to keep on filtering that out. That’s when you get diabetes, or people are suffering from inflammation, and it might be just a few ingredients that are in their diet. Instead of going on all these medications, if you just eliminate those foods, then you can feel better and be better. We look at the cures in the kitchen or try to help people to understand that direct correlation of how you feel is data based on what you eat.”

In any case, it will be fascinating to see how the different players design their strategies.